Rationale 1: It is unrealistic to expect that the nurse will speak the patients primary language if it is not English.
Reference: Page 56

Rationale 2: Many of the clinical assessment instruments have not been validated for use with ethnic minorities.
Reference: Page 56

Rationale 3: To avoid stereotypical thinking, the nurse must approach each patient as a unique individual.
Reference: Page 56

Rationale 4: Knowing the prevalence, incidence, and risk factors for diseases specific to different ethnic groups is a component of cultural competence in healthcare.
Reference: Page 56

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Identify the nurses role in the geriatric assessment process.

Question 3

Type: MCMA

The nurse is completing the minimal data set (MDS) for an older patient. What are characteristics of this assessment?

Standard Text: Select all that apply.

1. Eliminates listing the patients prescribed medications

2. Identifies health insurance coverage that is not Medicare or Medicaid

3. Provides a multidimensional view of the patients functional capacities

4. Used primarily to determine the amount of funding the patient has for long-term care

5. Includes a core set of screening, clinical, and functional measures used in patient assessment

Correct Answer: 3,5

Rationale 1: Medication information is needed since this may impact the patients ability to function.
Reference: Page 56

Rationale 2: The MDS is a standardized assessment tool that forms the foundation for all residents of long-term care facilities certified to participate in Medicare or Medicaid.
Reference: Page 56

Rationale 3: The items in the MDS give a multidimensional view of the patients functional capacities.
Reference: Page 56

Rationale 4: The MDS is used to for validating the need for long-term care, reimbursement, ongoing assessment of clinical problems, and assessment of and need to alter the current plan of care.
Reference: Page 56

Rationale 5: The MDS includes categories that measure physical, psychological, and psychosocial functioning of the patient.
Reference: Page 56

The nurse is preparing to use the SPICES tool to assess an older patient. Which areas will the nurse assess with this tool?

Standard Text: Select all that apply.

1. Incontinence

2. Sleep disorders

3. Skin breakdown

4. Evidence of falls

5. Lower limb function

Correct Answer: 1,2,3,4

Rationale 1: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Incontinence is assessed in this tool.
Reference: Page 52

Rationale 2: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Sleep disorders are assessed in this tool.
Reference: Page 52

Rationale 3: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Skin breakdown is assessed in this tool.
Reference: Page 52

Rationale 4: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Evidence of falls is assessed in this tool.
Reference: Page 52

Rationale 5: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Lower limb function is not assessed in this tool but is assessed in the PULSES profile.
Reference: Page 52

The family of an older patient in a nursing home has contacted the ombudsmen program. What will the ombudsman do for the patient?

1. Investigate the complaint.

2. Deter the patient from filing a lawsuit.

3. Pursue a lawsuit on behalf of the patient.

4. Review the patients record and determine if appropriate care has been given.

Correct Answer: 1

Rationale 1: All states are to operate long-term care ombudsmen programs. These programs provide trained people to investigate complaints made by residents and families about care received in the facility.
Reference: Page 61

Rationale 2: There is not a particular person or healthcare employee who would specifically deter a patient from filing a lawsuit.
Reference: Page 61

Rationale 3: Attorneys are those who pursue lawsuits for patients in nursing homes.
Reference: Page 61

Rationale 4: An expert witness is a healthcare expert who reviews patient records and offers opinions as to whether patients have received the appropriate standard of care.
Reference: Page 61

Which scenario describes a situation in which the performance of the nurse does not meet the standard of care?

1. A nurse witnesses a patient fall and tries to assist the patient.

2. A patient with vomiting and nausea does not receive a breakfast tray.

3. A physician is questioned about an order to administer a medication that is five times the normal dosage.

4. A patient is medicated with acetaminophen for severe chest pain and the physician is not notified.

Correct Answer: 4

Rationale 1: Assisting a patient who has fallen is a situation in which a reasonable nurse would pursue a similar action and would be considered the standard of care.
Reference: Page 62

Rationale 2: Withholding a breakfast tray from a patient who is nauseated and vomiting is a situation in which a reasonable nurse would pursue a similar action and would be considered the standard of care.
Reference: Page 62

Rationale 3: Questioning a medication dosage outside the normal range is a situation in which a reasonable nurse would pursue a similar action and would be considered the standard of care.
Reference: Page 62

Rationale 4: Medicating a patient with acetaminophen for severe chest pain and not notifying the physician would not be considered standard care for chest pain.
Reference: Page 62

What actions will the nurse follow when using restraints for an older patient in a long-term care facility?

Standard Text: Select all that apply.

1. Use restraints for 2 hours or less.

2. Obtain a physicians order before using.

3. Waist restraints are the best approach to prevent patient falls.

4. Remove the patients eyeglasses when applying restraints.

5. Consider the use of restraints for emergency situations only.

Correct Answer: 1,2,5

Rationale 1: Restraints are now limited to short-term use of 2 hours or less.
Reference: Page 63

Rationale 2: Restraints are used only with a physicians order.
Reference: Page 63

Rationale 3: Waist restraints are not proven to be the best approach to prevent patient falls. Nurses are urged to develop alternatives to physician restraints such as addressing patient and environmental factors.
Reference: Page 63

Rationale 4: The nurse should make sure the patient is wearing eyeglasses, which would reduce the need to use a restraint.
Reference: Page 63

Rationale 5: Restraints are to be ordered by a physician in emergency situations.
Reference: Page 63

The gerontological nurse is planning health promotion actions for an older patient. What information would the nurse take into consideration when planning these actions?

Standard Text: Select all that apply.

1. Patient has type 2 diabetes mellitus

2. Patient uses BIPAP machine for sleep apnea

3. Patient walks for 30 minutes 3 times a week

4. Patient attends religious services every Sunday morning

5. Patient lives alone and volunteers at the local library most afternoons

Correct Answer: 3,4,5

Rationale 1: Health promotion for the older adult is not focused on disease or disability. Type 2 diabetes mellitus would not need to be taken into consideration for the patient.
Reference: Page 60

Rationale 2: Health promotion for the older adult is not focused on disease or disability. Using a BIPAP machine for sleep apnea would not need to be taken into consideration for the patient.
Reference: Page 60

Rationale 3: Health promotion for the older adult is focused on individual strengths, abilities, and values. Walking for 30 minutes 3 times a week would be taken into consideration for the patient.
Reference: Page 60

Rationale 4: Health promotion for the older adult is focused on individual strengths, abilities, and values. Attending religious services every Sunday would be taken into consideration for the patient.
Reference: Page 60

Rationale 5: Health promotion for the older adult is focused on individual strengths, abilities, and values. Living alone and volunteering at the local library most afternoons would be taken into consideration for the patient.
Reference: Page 60

Rationale 4: Faxing patient test reports to a machine that is shared by the payroll department could violate the confidentiality of patient medical information. Further action would be needed for this situation.
Reference: Page 65

The nurse is concerned that a patients privacy could be breached according to the Health Insurance Portability and Accountability Act (HIPAA) standards. Which situation would be a breach of the HIPAA standards?

1. Copies of the patients diagnostic test results are shredded before being discarded.

2. A nurse discusses the patients condition with a relative without the patients permission.

3. A physician who is not a caregiver of the patient is restricted from access to the patients chart.

4. The patients chart is stored in the secured office of the radiology office while the patient is having a diagnostic examination done.

Correct Answer: 2

Rationale 1: Copies of patient records must be rendered unreadable before being discarded.
Reference: Page 65

Rationale 2: A breach in patient privacy is the nurse discussing the patients condition with a relative without the patients permission.
Reference: Page 65

Rationale 3: Persons, including healthcare professionals, who do not legitimately need to see a patients record, must be kept from accessing the record.
Reference: Page 65

Rationale 4: Patient records must be secure, especially when used in departments other than the nursing unit.
Reference: Page 65

3. Administer the blood transfusion since a signed consent form is not necessary.

4. Explain the transfusion, help the patient sign the consent, and administer the transfusion.

Correct Answer: 1

Rationale 1: The nurse who finds a patient lacking the capacity to provide consent, as in the case of a confused patient, must obtain consent from a healthcare proxy, such as the durable power of attorney.
Reference: Page 65

Rationale 2: Withholding the transfusion until the patient is no longer confused delays the treatment and may result in harm to the patient.
Reference: Page 65

Rationale 3: A blood transfusion is considered a specialized procedure and requires a separate informed consent form be signed.
Reference: Page 65

Rationale 4: Explaining the treatment to a confused patient and then assisting the patient to sign the consent does not meet the test of capacity for consent (understanding, reasoning, problem solving, and communicating the decision).
Reference: Page 65

An older patient recently admitted from a homeless shelter experiences cardiac arrest. The patient has no resuscitation orders. What should the nurse do first?

1. Notify the shift supervisor.

2. Notify the homeless shelter.

3. Notify the admitting physician.

4. Begin cardiopulmonary resuscitation.

Correct Answer: 4

Rationale 1: The supervisor will need to be notified, but it is not the first step to be taken.
Reference: Page 67

Rationale 2: The homeless shelter would have no jurisdiction over the patient.
Reference: Page 67

Rationale 3: The physician will need to be notified, but it is not the first step to be taken.
Reference: Page 67

Rationale 4: If resuscitation orders are not present, the nurse should begin cardiopulmonary resuscitation on the patient.
Reference: Page 67

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Recognize the importance of and need to identify and communicate advance directives when caring for the older adult.

Question 18

Type: MCSA

An older patient is diagnosed with an intestinal obstruction and needs immediate surgery. The patients next of kin is a granddaughter who lives in a neighboring community. Who will the nurse ask to sign the consent form for the surgery?

1. The patient

2. The patients daughter

3. The patients granddaughter

4. Both the patient and granddaughter

Correct Answer: 1

Rationale 1: Unless there has been some indication of a loss of competence or a legal document exists that establishes the power of attorney, the patient has the responsibility to sign the consent form for the surgery.
Reference: Page 66

Rationale 2: The daughter is not responsible for signing the consent form. The patient can sign the consent for the surgery.
Reference: Page 66

Rationale 3: The granddaughter is not responsible for signing the consent form. The patient can sign the consent for the surgery.
Reference: Page 66

Rationale 4: The granddaughter is not responsible for signing the consent form. The patient can sign the consent for the surgery.
Reference: Page 66

The nurse is preparing consent forms for a newly admitted older patient to sign. For which reasons would a general consent form be needed?

Standard Text: Select all that apply.

1. Help with feeding.

2. Provide medications.

3. Assist with bathing.

4. Perform all invasive procedures.

5. Participate with dressing after morning care.

Correct Answer: 1,2,3,5

Rationale 1: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as helping with feeding.
Reference: Page 66

Rationale 2: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as providing medications.
Reference: Page 66

Rationale 3: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as assisting with bathing.
Reference: Page 66

Rationale 5: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as participating with dressing after morning care.
Reference: Page 66

An older homeless patient is admitted to the hospital. The patient has no known family, is unresponsive, and his condition is considered guarded. What should be done to ensure appropriate healthcare decisions are made for this patient?

1. The homeless shelter will provide direction.

2. The patient will be represented by the hospital social worker.

3. The hospital will make decisions for the patients healthcare.

4. The hospital will ask a judge to appoint a guardian for the patient.

Correct Answer: 4

Rationale 1: If an older person lacks decisional capacity and has no predetermined wishes, family, or healthcare proxy, the care facility may seek a court-appointed guardian who is appointed by a judge to act on behalf of the ward or the patient. The homeless shelter will not be consulted in this situation.
Reference: Page 66

Rationale 2: If an older person lacks decisional capacity and has no predetermined wishes, family, or healthcare proxy, the care facility may seek a court-appointed guardian who is appointed by a judge to act on behalf of the ward or the patient. The hospital social worker will not make decisions for the patient.
Reference: Page 66

Rationale 3: If an older person lacks decisional capacity and has no predetermined wishes, family, or healthcare proxy, the care facility may seek a court-appointed guardian who is appointed by a judge to act on behalf of the ward or the patient. The hospital will not make decisions for the patient.
Reference: Page 66

Rationale 4: If an older person lacks decisional capacity and has no predetermined wishes, family, or healthcare proxy, the care facility may seek a court-appointed guardian who is appointed by a judge to act on behalf of the ward or the patient.
Reference: Page 66